From the Guidelines
The plan of care for Kristen, a patient with bipolar disorder and recent suicide attempt, should focus on immediate safety measures and stabilization of her mental health condition, with continued inpatient psychiatric hospitalization and implementation of suicide watch protocol, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.
Key Components of the Plan
- Continued inpatient psychiatric hospitalization for at least 72 hours to ensure safety and stabilization of her mental health condition
- Implementation of suicide watch protocol and daily assessment of suicidal ideation to closely monitor her mental state
- Removal of all potential means of self-harm from her environment to prevent further attempts
- Review and optimization of her medication regimen, including consideration of increasing her Seroquel dose as she has expressed willingness for better mood stabilization, and evaluation of the recent reduction of Lamictal from 200mg twice daily to 25mg
- Psychoeducation on bipolar disorder and medication adherence to empower her with knowledge and skills to manage her condition
- Evaluation of her interrupted hormone replacement therapy, possibly with endocrinology or gynecology consultation, as hormonal fluctuations may impact mood stability
- Starting a probiotic supplement for gastrointestinal health to promote overall well-being
- Exploration of psychosocial stressors, including her family situation with her husband and daughter with autism, and provision of appropriate interventions to address these stressors
Rationale for the Plan
The plan is based on the most recent and highest quality evidence, including the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1, which recommend a comprehensive approach to managing patients at risk for suicide. The guidelines emphasize the importance of immediate safety measures, stabilization of mental health conditions, and addressing underlying factors contributing to suicidal thoughts. Additionally, the plan incorporates elements of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT), which have been shown to be effective in reducing suicidal ideation and behavior 1.
From the FDA Drug Label
Quetiapine is not approved for the treatment of patients with dementia-related psychosis [ see BOXED WARNING]. 5. 2 Suicidal Thoughts and Behaviors in Adolescents and Young Adults Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs.
The patient's plan of care should include:
- Close monitoring for suicidal thoughts and behaviors
- Assessment of the patient's safety and suicidal ideation daily
- Optimization of the current medication regimen, considering the patient's history of bipolar disorder and recent suicidal attempt
- Psychoeducation on bipolar disorder and medication adherence
- Exploration of underlying factors contributing to suicidal thoughts and provision of appropriate interventions
- Consideration of adjusting medications if necessary, under the guidance of a healthcare professional 2
From the Research
Assessment and Plan
The patient, Kristen, presents with a history of bipolar disorder, recent suicidal ideation, and a suicide attempt. The plan of care should address the following key areas:
- Suicide Attempt and Suicidal Ideation: Kristen's recent suicide attempt and ongoing suicidal ideation require immediate attention. The plan should include:
- Continuing inpatient psychiatric hospitalization for at least 72 hours
- Implementing suicide watch protocol
- Assessing patient's safety and suicidal ideation daily
- Providing close monitoring and removing potential means of self-harm
- Exploring and addressing underlying factors contributing to suicidal thoughts, as suggested by 3 and 4
- Bipolar Disorder: Kristen's known diagnosis of bipolar disorder and history of multiple psychiatric hospitalizations require optimization of her medication regimen. The plan should include:
- Reviewing and optimizing current medication regimen
- Considering adjusting medications if necessary, such as lithium, which has been shown to have anti-suicidal effects in bipolar disorder 5, 6
- Providing psychoeducation on bipolar disorder and medication adherence
- Exploring psychosocial stressors and providing appropriate interventions
- Medication Management: Kristen is currently taking Seroquel 250mg and expresses willingness to increase the dose for better mood stabilization. The plan should include:
- Evaluating the effectiveness of current medication regimen
- Considering increasing the dose of Seroquel, as it has been shown to be effective in treating bipolar depression 7
- Monitoring for any potential side effects or interactions with other medications
- Hormone Replacement Therapy Interruption: Kristen's hormone replacement therapy was interrupted during her current treatment and hospitalization. The plan should include:
- Evaluating the need for resuming hormone replacement therapy
- Consulting with endocrinology or gynecology if necessary
- Monitoring for any mood changes related to hormonal fluctuations
Key Considerations
- Kristen's history of bipolar disorder and suicidal ideation requires close monitoring and a comprehensive treatment plan.
- The use of lithium and other medications with anti-suicidal effects should be considered, as suggested by 5 and 6.
- Psychological pain and fearlessness about death may function as transitional factors that are associated with the transition from desire to suicidal intent, as suggested by 4.
- A 'two-take' approach to short-term risk assessment and mitigation should be considered, taking into account variability in severity of intent, as suggested by 3.